OCT 2016 vol. 01 iss. 03

Education PracticeResearch

Editorial Board

Emergency Department/FASTDr. Joseph Newbigging, MDDr. Louise Rang, MD

Critical CareDr. Suzanne Bridge, MD

AnesthesiologyDr. Rob Tanzola, MDDr. Rene Allard, MD

Internal MedicineDr. Barry Chan, MD

CardiologyDr. Amer Johri, MDJulia Herr, MSc

Case Files:

Rapid Diagnosis of Pericardial Effusion

Case Reports:

FAST Ultrasound Interpretation in Trauma Resuscitation

Incarcerated femoral hernia containing ovary, unusual presentation of uncommon groin hernia

ISSN: 2369­8543

12 | POCUS J | OCT 2016 vol. 01 iss. 03

Visit the online article to view additional content from these cases: pocusjournal.com/article/2016­01­03p12

Mr. DB was a 95 year old man who presented to the emer­

gency department with dyspnea pro­gressing over the last 3 months. Chest x­ray demonstrated an en­larged cardiac silhouette.

He had a past medical history signi­ficant for coronary artery disease, hypertension and a lobectomy due to tuberculosis.

A point of care cardiac ultrasound was conducted by an internal medi­cine resident as part of his physical examination in the emergency de­partment. A large pericardial effu­sion was found. There were no clinical signs of tamponade.

Video 1 (online supplement; Figure 1) demonstrates a parasternal long axis view with the pericardial effu­sion noted to be posterior to the left ventricle in this view. Video 2 (on­line supplement; Figure 2) is a short axis view of the heart which is show­ing that the effusion is surrounding the heart. Video 3 and 4 (online supplements; Figures 3 & 4) demon­strates that the pericardial effusion is present significantly surrounding the apex as well. An echocardiogram confirmed the POCUS findings and cardiology was consulted to conduct a pericardiocentesis, following which the patient’s symptoms resolved. The effusion was thought to be chronic and transudative. In this case, the use of POCUS at the bed­side allowed for rapid detection of a large pericardial effusion and sub­sequent treatment.

Case Files

Rapid diagnosis of pericardial effusionby Jeffrey Wilkinson, MD and Amer M. Johri, MD

Queen's University, Department of Medicine

Figure 3. Four­chamber view de­picting significant pericardial effu­sion surrounding the apex. (See online Video 3).

Figure 1. Parasternal long axis view with pericardial effusion. (see online Video 1).

Figure 2. Parasternal short axis view with pericardial effusion. (See online Video 2).

Figure 4. Close­up of four­chamber view depicting significant pericardial effusion surrounding the apex next to the left ventricle. (See online Video 4).

OCT 2016 vol. 01 iss. 03 | POCUS J | 13 Case Report

FAST ultrasound interpretation in trauma resuscitation

FAST Background

Focused Assessment with Sono­graphy for Trauma (FAST) is an

integral adjunct to primary survey in trauma patients (1­4) and is incor­porated into Advanced Trauma Life Support (ATLS) algorithms (4). A col­lection of four discrete ultrasound probe examinations (pericardial sac, hepatorenal fossa (Morison’s pouch), splenorenal fossa, and pel­vis/pouch of Douglas), it has been shown to be highly sensitive for de­tection of as little as 100cm3 of in­traabdominal fluid (4,5), with a sensitivity quoted between 60­98%, specificity of 84­98%, and negative predictive value of 97­99% (3).. Fur­ther increasing sensitivity, ATLS re­commends a repeat FAST exam in 30 minutes to increase sensitivity in slow bleeds, or early post­trauma presentations in the case that the first exam was negative (4). Re­cently, the Extended FAST (E­FAST) exam has become standard and in­cludes assessment for post­traumat­ic pneumothoraces (6).

With respect to trauma resuscitation, FAST exam offers the opportunity for quick, serial exams to identify poten­tially fatal conditions, including peri­toneal free fluid and pericardial tamponade (1). It is indicated for the triage of blunt trauma patients (7) to direct decision making (1). In penet­rating abdominal trauma FAST se­lects for patients requiring emergent exploratory laparotomy (5).

Case Summary

A 38­year old male was transferred to a Level 1 Trauma Center from a peripheral Emergency Department. Approximately four hours prior he was a belted front­passenger in a motor vehicle collision with intrusion to the passenger side at speeds ap­proximately 50km/h. There was no loss of consciousness, but the pa­tient endorsed sudden right­sided abdominal pain. Upon arrival at the

peripheral Emergency Department, the patient was tachycardic between 130­150bpm, though hemodynamic­ally stable. Primary survey identified right upper and lower abdomen ten­derness, persistent tachycardia des­pite crystalloid resuscitation, and peritoneal free fluid on E­FAST ex­am.

Upon arrival at the Level 1 Trauma Center, the patient remained tachy­cardic and demonstrated localized right lower quadrant peritonitis. A repeat E­FAST exam was positive for intraperitoneal free fluid in Moris­on’s pouch (see Figure 1). After fur­ther resuscitation, the patient was hemodynamically stable enough to undergo CT imaging of the abdo­men/pelvis. The CT demonstrated a large right­sided retroperitoneal complex fluid collection measuring 82 x 132 x 172 mm that extended from the posterior pararenal space to the peritoneal fat anteriorly. Mottled locules of gas were evident

by Stuart Douglas1, Joseph Newbigging2, David Robertson3

(1 ) PGY4 Emergency Medicine, Queen’s University, and Fellow Critical Care Medicine, Queen’s University (2) Assistant Professor, Queens University, Division of Emergency Medicine(3) Assistant Professor, Queens University, Division of General Surgery

within the collection, suspicious for traumatic colonic perforation. There was also fluid in Morison’s pouch (see Figure 2), consistent with what was seen on the E­FAST exam. As such, the patient was emergently taken to the Operating Room (OR) for exploratory laparotomy.

Intraoperatively, a large abscess with chronic features was identified in the right lower quadrant. It was contiguous with the retroperitoneum and dissected towards the right groin in the peri­psoas plane. The grossly abnormal appendix was identified within the abscess. Based on the operative findings, a tentative diagnosis of a chronic missed ap­pendicitis was made, rather than acute traumatic bowel perforation. The patient underwent open ap­pendectomy and wash­out, and was discharged from hospital in excellent condition two weeks later.

Of note, following the OR, the pa­

Figure 1. Right upper quadrant of FAST scan showing free fluid (yellow arrow) on Morison’s pouch.

14 | POCUS J | OCT 2016 vol. 01 iss. 03

Visit the online article to view additional content from this case: pocusjournal.com/article/2016­01­03p13­14

tient reported that he had been as­sessed for right lower quadrant pain and diagnosed with a partial small bowel obstruction one month prior to this presentation. He reported ongo­ing abdominal pain and significant weight loss since that assessment. In retrospect, it was felt that his ori­ginal small­bowel obstruction dia­gnosis was actually an ileus from acute appendicitis.

Limitations of FAST

E­FAST exam has become an integ­ral adjunct to trauma resuscitation. In skilled hands it is a powerful tool with ability to drastically improve pa­tient outcomes. Although fast, non­invasive, and sensitive, E­FAST ex­amination should be interpreted skilfully. An appreciation for E­FAST limitations and sensitivity is required for successful trauma resuscitation.

Of note, decreased sensitivity for in­tra­abdominal injury has been linked to specific patient populations, in­cluding those with higher Injury Severity Scores (3), and hemody­namically stable patients with blunt abdominal injury (7). Negative FAST exams in these cohorts should be interpreted with caution, and consid­

eration of further investigations or serial exams considered. Further re­cognized limitations include failure to identify retroperitoneal or solid or­gan injuries, failure to recognize clotted blood as hematoma, and dif­ficult patient groups including those that are obese (8).

As portrayed in this case report, E­FAST offers little ability to discern the specific fluid identified (8). Free fluid on E­FAST could be blood, but could also be urine, ascites, bile, pus, peritoneal dialysate fluid, or bowel contents. In the setting of trauma, peritoneal free fluid must be considered blood, and the trauma patient resuscitated appropriately, with CT imaging as tolerated versus emergent exploratory laparotomy. This case illustrates an interesting example of a trauma patient’s E­FAST exam that was falsely positive for blood in the peritoneum.

References1. Kool DR, Blickman JG. Advanced trauma life support. ABCDE from a radiological point of view. Emerg Radiol. 2007;14:135­141.2. Jehle DVK, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg med. 2003;21:476­478. 3. Becker A, Lin G, McKenney MG, Marttos A, Schulman CI. Is the FAST exam reliable in severely injured patients? Injury. 2010;41(5):479­483.4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors – ATLS Student Course Manual, Eighth Edition. Chicago: American College of Surgeons, 2008. Print. 5. Quinn AC, Sinert R. What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma? Injury. 2011;42:482­4876. Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S. Hand­held thoracic sonography for detecting post­traumatic pneumothoraces: The Extrnded Focused Assessment with Sonography for Trauma (EFAST). The Journal of Trauma. 2004. 57;288­295.7. Miller MT, Pasquale M, Bromberg WJ, Wasser T, Cox J. Not so Fast. The Journal of Trauma: Injury, Infection, and Critical Care. 2003;54(1):52­60.8. Lewiss RE, Saul T, Del Rios M. “Focus on: EFAST – Extended Focused Assessment with Sonography for Trauma.” American College of Emergency Physicians – Clinical & Practice Management. American College of Emergency Physicians. Jan, 2009. Web June 13, 2016.

Figure 2. Axial image CT abdomen demonstrating free fluid to Morison’s pouch.

OCT 2016 vol. 01 iss. 03 | POCUS J | 15 Case Report

Incarcerated femoral hernia containing ovary, unusual presentation of uncommon groin hernia

by Priyank Gupta, MD, FRCR1; Hadiel Kaiyasah, MRCS Glasgow2; Mahra AlSuwaidi, MRCS Glasgow2

(1) Dubai health authority, Rashid hospital, radiology department, UAE.(2) Dubai health authority, Rashid hospital, general surgery department, UAE.

Of all groin hernias, femoral her­nias account for around 2–8%.

They occur four to five times more commonly in females than males and have a peak incidence in those between 30 and 60 years old [1,2]. In adult population, femoral hernias are more commonly found in pa­tients with previous inguinal hernia repair [3]. We present an unusual case of a 28 ­year­old woman who presented to our institution with an incarcerated femoral hernia contain­ing the right ovary & fallopian tube occurring after inguinal hernia repair. The point of care ultrasound that was done in the emergency depart­ment had helped in prompt diagnos­is of the condition, hence sending the patient to operation theatre for urgent surgical intervention.

Case Presentation: A 28­year­old female presented to the emergency department with a sudden onset of abdominal pain in the right iliac fossa and suprapubic area. The pain was dull, mild to moderate in sever­ity with no radiation. Patient gave history of chronic right groin swelling that was reducible for the last 2 months. Prior to presentation to ac­cident & emergency department, she developed an irreducible swell­ing. There was no associated vomit­ing or constipation. Of note in her surgical history was significant for Left inguinal hernia repair ten years ago. She was normotensive and afebrile at presentation. Examination revealed a scar in the left inguinal region. Her abdomen was soft. There was an irreducible firm tender lump palpated below the level of the right inguinal ligament and lateral to the pubic tubercle.

Investigations: All her laboratory tests were within normal limits. The patient was reviewed by the surgical oncall doctor who made the provi­sional diagnosis of irreducible right femoral hernia based on the clinical

examination. Initially a point of care ultrasound (POCUS) was done by the attending surgical doctor, who was able to appreciate a localized cystic swelling within the hernia sac. A departmental Ultrasonography of the right groin area was obtained to confirm the findings of POCUS. It re­vealed a well­defined rounded soft tissue echogenicity lesion with a well defined cystic component containing no internal septations or mural nod­ules. The lesion was located subcu­taneously anterior & medial to the femoral vein & reaching medially up to the level of pubic symphysis with no obvious intra­abdominal exten­sion (Figure 1A). The lesion was not reducible and did not change in the size on Valsalva maneuver or cough impulse. No evidence of any peri­stalsis or free fluid noted within con­tents of the swelling. Color Doppler imaging revealed central branching pattern of vascularity consistent with ovarian vasculature pattern (Figure 1B). The ultrasound findings were in keeping with right femoral hernia with the ovary within the hernia sac.

Treatment: The patient was admit­ted under the care of the general surgery team with provisional dia­gnosis of an incarcerated right femoral hernia with a plan for urgent laparoscopic repair of the right femoral hernia. Intra­operatively, ex­ploration revealed no fluid in the ab­domen and no signs of bowel obstruction. A hernia sac was present protruding down towards the femoral canal. The contents were reduced & found to be the ovary and fallopian tube (online Figure S1). Both structures were looking viable. The anatomy of the area was clari­fied and dissected reaching to the pubic tubercle medially and the in­guinal ligament superiorly and later­ally. A prolene mesh was applied and fixed using endoscopic clips (takar). The peritoneum was closed and the abdomen deflated.

Outcome and Follow­Up: Patient was doing well post­operatively and responded well to the planned man­agement. She had an uneventful re­covery and was discharged home on the next day. Follow up after 6 weeks revealed no complication.

Discussion: The anatomical loca­tion of the ovaries and fallopian tube at a level below femoral ring makes herniation of these structures through it unusual, particularly in adults [4]. According to the most ac­ceptable theory, the primary cause for the formation of femoral hernia is a congenitally narrow posterior in­guinal wall attachment onto Cooper’s ligament with a resultant enlarged femoral ring, while the sec­ondary aetiology is a state of pro­longed and increased intra­abdominal pressure, which forces preperitoneal fat into the con­genitally large femoral ring [1,5,6]. However, it should be noted that in younger ages with femoral hernias, processes responsible for elevated intra­abdominal pressure are rarely encountered. Due to the rigid liga­mentous borders & relatively narrow lumen, incarceration occurs more frequently in femoral hernias than other abdominal hernias [7,8]. The incidence of recurrent femoral hernia occurring after inguinal herniorraphy has been reported to be up to 35% [8]. The increased incidence of femoral hernia after inguinal hernior­raphy may be due to an overlooked hernia or a new spontaneous hernia due to weakening of the femoral re­gion caused by inguinal hernior­raphy [8,9]

Femoral hernias typically present as a painless or painful groin lump, al­though may present simply as groin pain or with features of their com­plications such as obstruction. The differential diagnoses include inguin­al hernia, lipoma, saphena varix, en­larged lymph nodes, femoral artery

16 | POCUS J | OCT 2016 vol. 01 iss. 03

aneurysm, sarcoma, obturator her­nia, psoas abscess, psoas bursa, and in males, ectopic testis [4,10]. Different contents in femoral hernias have been reported in the literature, such as small intestine, omentum, bladder, cecum, colon, appendix (what is known as De Garengeot’s hernia), Meckel’s diverticulum (Littre hernia), testis, ovary, and even stomach or kidney [11,12].

The preoperative diagnosis of femoral hernia is a challenging is­sue. In previous reports, the clinical diagnostic accuracy ranged from 25% to 40% [13]. The ovary is quite sensitive to ischemia [14,15]. Should it tort or become incarcerated in a femoral hernia sac, a delay in dia­gnosis may necessitate its resection [16]. Imaging studies could prove to be a valuable preoperative investig­ation in women of childbearing age presenting with femoral hernia. Nowadays POCUS is a valuable tool in the initial assessment of irredu­cible hernia cases, whether per­formed by the emergency physician or the attending surgeon. The most important points to keep in mind while performing POCUS are:

• Femoral hernia is visualized as a subcutaneous swelling in contact with the femoral vein.

• Assess the contents of hernia sac, whether loop of bowel within or a cystic swelling (e,g ovary like in our case).

• In cases where bowel loops are within a hernia sac, observe for signs of strangulation, such as oed­ematous bowel wall or absent peri­stalsis.

Doppler ultrasound may identify re­duced blood flow in ovaries suggest­ive of torsion. Cross­sectional

imaging with CT may be similarly beneficial in identifying a groin her­nia containing an ovary provided it causes no delay in the timing of sur­gery [17].

Operative management of an incar­cerated femoral hernia containing an ovary follows the same surgical prin­ciples for femoral hernia repair. In­traoperative Reduction of the sac content should be attempted in re­productive young woman and chil­dren without any ovarian and tubal abnormalities [18], provided that any life­threatening complication such as acute salpingitis does not exist [19]. If the ovary can't be preserved due to inviability, a salpingo­oophorec­tomy is to be undertaken. Hernia re­pair could be done via mesh plug repair, which is considered to have the lowest recurrence rate [1].

Conclusion: Incarcerated femoral hernia containing ovary, is an un­usual presentation of uncommon groin hernia. The point of care ultra­sound that was done in the emer­gency department had helped in prompt bedside clinical diagnosis of the condition, hence early urgent surgical intervention & better out­come.

Visit the online article to view additional content from this case: pocusjournal.com/article/2016­01­03p15­16

hernia. Ann Surg 1961; 154(6):25­32.7. Ichinokawa M, Okada T, Sasaki F. Incarcerated femoral hernia with ovary and fallopian tube torsion in an infant: a rare occurrence. Pediatr Surg Int 2008; 24:1149–51. 8. Ludington LG. Femoral Hernia and Its Management: With Particular Reference to Its Occurrence Following Inguinal Herniorrhaphy. Ann Surg 1958; 148(5):823­826.9. Glassow F. Recurrent inguinal and femoral hernia. Brit Med J 1970; 1(5690):215­216.10. Alzaraa A. Unusual contents of the femoral hernia. ISRN Obstet Gynecol 2011; 2011:717924. 11. Zacharakis E. An unusual presentation of Meckel diverticulum as strangulated femoral hernia. South Med J 2008; 101:96­98.12. Marioni P. Metastatic carcinoma with small intestine in a femoral hernia. Can Med Assoc J 1960; 82:1081­1082.13. Al­Shanafey S, Giacomantonio M. Femoral hernia in children. J Pediatr Surg 1999; 34:1104­1106. 14. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005; 159:532­55.15. Yamashita Y, Sowter M, Ueki M, et al. Adnexal torsion. Aust N Z J Obstet Gynaecol 1999; 39:174­7.16. Gurer A, Ozdogan M, Ozlem N, et al. Uncommon content in groin hernia sac. Hernia 2006; 10:152­5.17. Suzuki S, Furui S, Okinaga K, et al. Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol 2007; 189:W78–83.18. Amarin ZO, Hart DM. Inguinal ovary and fallopian tube—an unusual hernia. Int J Gynaecol Obstet 1988; 27:141­143.19. Roth CG, Varma JD, Tello R. Gastrointestinal/genitourinary case of the day. Incarcerated inguinal hernia of the left fallopian tube and ovary. AJR Am J Roentgenol 1999; 173:787, 791­792.

References:1. Hachisuka T. Femoral hernia repair. Surg Clin North Am 2003; 83:1189–205. 2. Lytle WJ. Inguinal anatomy. J Anat 1979; 128(Pt 3):581–94. 3. Mikkelsen T, BayNielsen M, Kehlet H. Risk of Femoral hernia after inguinal herniorrhaphy. Br J Surg 2002; 89:486­488.4. King R. Congenital, strangulated femoral hernia in an infant aged six months containing the ovary and fallopian tube. Br J Clin Pract 1978; 32(7):209–210.5. Dahlstrand U, Wollert S, Nordin P, et al. Emergency femoral hernia repair: a study based on a national register. Ann Surg 2009; 249(4):672–676. 6. McVay CB, Savage LE. Etiology of femoral

Figure 1. Transverse view of the ultrasound scan of the groin swelling revealed ovary lying anterior & medial to the femoral vein

OCT 2016 vol. 01 iss. 03 | POCUS J | 17

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Physicians, Researchers, and Educators are invited to contribute articles to upcoming issues of POCUS Journal.

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ISSN: 2369­8543

The online version of the OCT 2016 issue of POCUS Journal is available at pocusjournal.com/issue/vol­01­iss­03­2016 and includes additional media and images from the case studies.